17A-122 (2) 60 CLAIRE AVE BP-2017-0831
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A- 122 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2017-0831
Project# JS-2017-001389
Est.Cost: $2345.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License: •
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(su.ft): 31276.08 Owner: PAWLOSKI JAMES W&JEAN K
Zoning: RI(too)/URA(100)/ Applicant: AMERICAN INSTALLATIONS LLC
AT: 60 CLAIRE AVE
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:1/5/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:ATTIC & BASEMENT INSULATION AND AIR
SEALING THROUGHOUT
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 1/5/2017 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Fite a BP-2017-0831
APPLICANT/CONTACT PERSON AMERICAN INSTALLATIONS LLC
ADDRESS/PHONE 130 COLLEGE ST SOUTH HADLEY (413)552-0200
PROPERTY LOCATION 60 CLAIRE AVE
MAP 17A PARCEL, 122 001 ZONE RI(109)/URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Type Construction: ATTIC& BASEMENT INSULATION AND AIR SEALING THROUGHOUT
New Construction
Non Structural interior renovations
Addition to Existing Y* n.
Accessory Structure
Buildin¢,Plans Included:
Owner/Statement or License 106178
3 sets of Plans I Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
//4pproved ... Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With She Plan
ZONING BOARD PERMIT REQUIRED UNDER: §_
finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition D- y
Signature of Buildi'g •'tet al Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A,Contact Office of
Planning& Development for more information.
16-2312
Department USe ordy
C of Northampton Status of Remit
httki ng Department tbirb CutlDiwevmy Pam*
' Tv. sers of sou'
\. Northampton,3 2 2 Maus Street Sewdrl6epacAva@a`
--'Room 100 WateriWell Availability
pt MA 01060 d41 Plarrs -
t ' phone 413-587-1240 Fax 413-587-1272 Ptwrsne Pians '
Other$pedry-
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH AONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 property Address: This section to be completed by office
60 Claire Avenue Map Lot Unit.
Florence,MA 0I062 Zane Overlay Distrtet
Elm St District CB District
SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Jean e'r James Pawloski 60 Claire Avenue Florence, MA 01062
Name(Pdnl) Current Melling Address:
(413)584 7007
See attached - Telephone
Signature
2.2 Authorized Agent
American Installations 130 College St., Ste 100 South Hadley,MA 01075
Name(Peng Current Mamma Address:
American Installations 413-552-0200
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $2,345.20 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Consbud!ontom(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fre Protection /,/^
6. Total=(1 +2+3+4+5) $2,345.20 Check Number - G s+0/;
This Section For Official Use Only
Budding Permit Number Date
Dated
Signature:
Brddalg Commissiariedinspector of Bullrings Dal
Section 4. ZONING AB Information Must Be Completed.Permit Can Be Denied Due To Incomplete Infohratlpa '
Existing Proposed Required byZoning
This column lobo filled in by
Building Department
Lot Size I I
Frontage I L__.
Setbacks Front I 1
Side L:1 It LI I R: I 1
Rear (—I I I
Building HeightI II I III
Bldg.Square Footage I % 1 1I
Open Space Footage %
Clot area minus bldg&paved I L I I I I�I
Parking)
#of Parking Spaces r—I i _j I I
Fill: F----------1
(volume&Landon)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW 0 YES O
IF YES,date issued:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES O
IF YES: enter Book I Page and/or Document#i_ I
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES,describe size,type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size,type and location:
E. Will the construction activity disturb(clearing,grading,excavation,ortilbng)over I acre or Is it part of a common plan
that will disturb over I acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
• SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House r] Addition ❑ Replacement Windows Alteratlon(s) ❑ Roofing 0
Or Doors 0
Accessory Bldg. 0 DemolItion D New Signs [Cj Decks (p Siding(a] Other(lt
Bdef Description of reposed
Wartc Attic and basement insulation and air sealing throughout
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Nanative Renovating unfinished basement Yes No
Plans Attached Rog -Sheet
Sa.If New hoose ander addition to existing housing,complete the.followlnq:
a. Use of building:One Family Two Family Other
b. Number of rooms In each family unit Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Canptianoe form attached?-
h. Type of construction
I. Is construction within 100 ft of wetlands? Yes No. Is consWctlon within 100 yr. floodplain Yes No
j. Depth of basement or actor floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City SewerT Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Jean 6-James Pawloski asOwner of the subject
pmperty
hereby authorize American Installations
to act on ray behalf,In a&matters mb.tive to work authorized by this building permit application.
See attached 1/3/17
Signature of Owner Date
I, American Installations as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and acuate,to the best of my kmrwledge
and belief.
Signed under the pains and penalties of perjury.
American Installations
Print Name
American Installations 1/3/17
Slants of OwneriAgen Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable Cl
Name of License Holder Wesley K. Couture 106178
License Number
130 College St., Ste 100 South Hadley, MA 01075 9/29/17
Address
Expirebon Date
Signature14,4( ��/ / 1e 552-0200
(J phone
9.Redisiered-Home improvement Contractor: - Not Applicable 0
Wesley Couture 175982
Company Name Registration Number
American Installations 6/27/17
Address Expiration Date
130 College St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the Issuance of the building permit.
Signed Affidavit Attached Yes..._.. B( No 0
11. r Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780. Sixth Edition Section 10835.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official.that hefshe shall be
responsible for all such work performed under the building pern t.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this pe®it
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
City of Northampton
/i•
Massachusetts t. F `4c
S�
DEPARTMENT OF BUILDING INSPECTIONS i
212 Main Strait a Municipal Building
`_..:-. Northampton, MA 01060 8/1�
Property Address: 60 Claire Avenue
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: South Hadley, MA
Phone: 43-552-0200
Property Owner d James Pawloski
Name:
Address: 60 Claire Avenue
City, State: Florence, MA 01062
I, American Installations (contractor) attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractorsi nature
12.E of
Date
1/3/17
S / l Amer nln:ullatins
•
B7-131
licensed&Insured
L• MA 6(X:106178
American Installations MA Registration#175982
L30 College Street Suite 100-South Hadley,MA 01075•Office:(4131552-0210 He(413)552-0202•Email:support@Amerkenlnstallatlom.com
Pawloski,Jean&James 12/19/2016
arai (kW
60 Claire Aye. Florence MA 01062
i.eml 413.584.7007 pawloskq@comcast.net p.m w
444947 (01) WW116-2312
WNIDI m
Quantity Unit Unit Cost Total
Air/Duct Sealing
AIR SEALING 10 man hour $ 8500 $ 85000
WEATHERSTRIP DOOR&ADD SWEEP 2 each $ 80.00 $ 160.00
Air/Duct Sealing $ 1,01000
Air/Duct Sealing Incentive $ (1,010.00)
Air/DUCE Selaing WX Balance $ -
Weatherizatlon
ATTIC HATCH-SEAL&INSULATE 1 each $ 60.00 $ 60. 0
ATTIC FLAT-5"OPEN R-19 CELLULOSE 960 soft $ 1.26 $ 1,209.60
ATTIC DAMMING-R-38 FIBERGLASS 32 sok $ 205 $ 65.60
Total Weatherization $ 1,335.20
Weatherization Incentive $ 1,001.40
Total Project $ 2,345.20
Total Utility Contribution $ 2,011.40
Total Customer Contribution $ 333.80
WARRANTY American numeono uC Stated wu w. the.awe e homeowner with a l year woman wanamy.
.eanlamnatmmoont LCCmrehntractwwoposesmeasna mmAh all material alabe to comrkplete the above scope of won m accordance with the above specifications and alor
lnnd nae building
ACCEPTANCE OF PROPOSAL The above prices,specifications and TOTAL CONTRACT VALUE_ $ 333.80
conditionssatisfactoryereby aceptd.You
authorized to do work as pecned.Payment will be 1/3 down prior to Down Payment= $ 111.00 C5 12-19-2016
start of work,and balance due upon Conn pletian. PA ID
Balance Due Upon Completion= $ 222.80
Pawloski,Jean&lames m. 12/19/2016
(00000(00)
Craig A.Dragovich / minT
'12-19-2016Her w-enw.law m.
THIS AGREEMENT 15 COMPOSED OFT1115 PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED.THIS AGREEMET IS
BETWEEN AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY",AND THE CUSTOMERISI NAMED ON THE REVERSE SIDE,HEREINAFTER REFERRED TO AS"CLIENT',AND
WILL BE SUBJECT TO ALL APPROPRIATE TAWS,REGULATIONS AND ORDINANCES OF THE STATE OF MASSACHUSETTS OR CONNECTICUT RESPECTIVELY,AS WELL A5 All LOCALJURISDICTIONS.
THE FOLLOWING TERMS AND CONCt1ONS ALSO APPLY
1.THIS AGREEMENT IS SUBJECT TO THE APPROVAL OF A MANAGER OF THE COMPANY FOR THIS AGREEMENT TO BE EFFECIVE UNDER ANY CONDITION.
2 SHOULD DEFAULT BE MADE IN TILE PAYMENT OFTHIS AGREEMENT,CHARGES SHALL BE ADDED FROM THE DATE THEREOF AT A RATE OF ONE AND ONE-HALF(11/2I PERCENT PER MONTH.
(18%PER ANNUM)WITH A MINIMUM CHARGE OF$1,00 PER MONTH,AND IF PLACED IN THE HANDS OF AN ATTORNEY OR COLLECTION AGENCY FOR COLLECTION,ALL ATTORNEYS'FEES,
EXPENSES AND COSTS OF COLLECTION SHALL BE PAID BY THE CLIENT.IN ADDITION.CLIENT UNDERSTANDS THAT IN FAILING TO PAY ACCORDING TO THE ABOVE TERMS COMPANY MAY
HAVETHERUNE MA LEN ON PEE BROPER_TC
3.THE COMPANY AGREES THAT WHEN DELAYS BECOME KNOWNTO THE(AMPANY,THE COMPANY WILL ADVISE THE CLIENT AS SOON AS REASONABLE.
4.COMPANY AGREES THAT,NOTWITHSTANDING ANY AGREEMENT FOR MATERIALS AND/OR LABOR BETWEEN COMPANY AND THIRD PARTY,COMPANY IS RESPONSIBLE TO CLIENT FOR
COMPLETION OF ALL WORK DESCRIBED IN A TIMELY AND WORKMANLIKE MANNER.
5.ALL WARRANTIES FOR EQUIPMENT AND PRODUCTS SUPPLIED BY THE COMPANY UNDER THIS AGREEMENT SHALL BE THOSE GIVEN BY'THE MANUFACTURERS OF SUCH EQUIPMENT AND
PRODUCTS,UNDER SUCH MANUFACTURER'S WARRANTIES,THE CLIENT MAY BE REQUIRED TO REGISTER OR MAIL INA WARRANTY CARD OF OTHER EVIDENCE OF OWNERSHIP AND USE OF
SUCH EQUIPMENT AND/OR PRODUCTS IN ORDER TO ACTIVATE 5001 WARRANTIES.
6.THE°NOTATION ON THE PAGE.HEREOF DOES NOT INCLUDE EXPENSES OR CHARGES FOR BOND OR INSURANCE PREMIUMS OR COSTS BEYONDNORMAL INSURANCE COVERAGE,ANY SUCH
ADDITIONAL EXPENSES,PREMIUMS OR COST SHALLBE ADDED TO THE TOTAL AGREEMENT AMOUNT,
7.THE COMPANY'S LIABILITY FOR CLAIMS ARISING OUT OF THIS AGREEMENT SHALL NOT EXCEED THE TOTAL AGREEMENT PRICE EXCEPT TO THE EXTENT THOSE DAMAGES ARE PROVEN TO BE
SOLER DUE TO THE COMPANY'S NEGLIGENCE.
S.DURING THE DURATION OF THE WORK,THE CLIENT'S HOMEOWNERS INSURANCE WILL BE RESPONSIBLE FOR ANY AND ALL DAMAGES AS LONG AS THE COMPANY HAS'TAKEN THE
APPROPRIATE ACTION TO PROTECT AREASOE WORN.
9 THE COMPANY IS NOT RESPONSIBLE FOR PREEXIS19NC DEFICENOES OR HAZARDOUS MATERIALS THAT MAMFEST THEMSELVES DURING THE CONSTRUCTION PROCESS_E-G.WOW ROT,
MOLD,ASBESTOS,NAIL POPS,DUCTWORK AND CONNECTIONS,PLUMBING AND VENT PIPES,DECXING DEFLECTION,ETC.IF A PRE-EXISONG DEFICIENCY OR HAZARDOUS MATERIAL IS
ENCOUNTERED PRIOR TO OR DURING CONSTRUCTION,AND COMPANY IS NOTIFIED IN WRITING,COMPANY WINTRY TO ASSIST CLIENT WITHIN THE COMPANY'S MEANS AND CAPABILITIES
TO CORRECT THE PROBLEMIS)ON A TIME AND MATERIAL BASIS.CLIENT AGREES THAT SUCH CONDITIONS ARE UNAVOIDABLE BY THE COMPANY AND SHALL NOT BE CONSIDERED A
VIOLATION OF THE AGREEMENT AND THAT DUE TC THESE CONDITIONS THE DURATION OF THE WORK AND SCHEDULED DATE OF COMPLETION MAY DIFFER PROM THAT AGREED UPON,IF
APPLICABLE,UNDER THIS AGREEMENT,
IO,TLE COMPANY R NOT RESPONSIBLE AND THE CLIENT AGREES TO HOLD THE COMPANY HARMLESS,FOR AW PROBLEMS AND/OR DAMAGES,INLNgNi BUT NOT LIMITED TO MOLD
GROWTH,ARISING FROMTHE PERFORMANCE OF AIM SEALING WORK BY THE COMPANY AS A RESULT OF ANY KNOWN OR UNKNOWN MOISTURE CONDITIONS.
11.THE COMPANY IS NOT RESPONSIBLE FOR,AND THE CLIENT AGREES TO MOLD THE COMPANY HARMLESS,FOR ANY PROBLEMS AND/OR DAMAGES RELATING TO ICE DAMMING THAT MAY
ARISE DURING AND/OR AFTER THE PERFORMANCE CF WORK BY THE COMPANY.
11.REPLACEMENT OF DETERIORATED DECKING,FASCIA BOARDS,ROOF JACKS,VENTILATORS,FLASHING,RAFTERS.JOISTS INSULATION OR OTHER MATERIALS ARE NOT INCLUDED UNLESS
OTHERWISE NOTED HEREIN.
H.THE COMPANY WILL NOT SE RESPONSIBLE FOR THE SCRATCHING OR DENTING OF INTERIOR WALLS AND CEILINGS,FLOORS,TRIM,GUTTERS,DOWNSPOUTS,EXISTING SIDING AND
WINDOWS,DOORS,OIL DROPLETS IN DRIVEWAYS,HAIRLINE FRACTURES IN CONCRETE OR BLACKTOP DRIVES AND WALK,OR DAMAGE TO PLANES OR SHRUBBERY.IF EXCESSIVE DAMAGE IS
CAUSED BY COMPANY,COMPANY WILL REPAIR OR REPLACE DAMAGED AREA ONLY AT COMPANY'S EXPENSE.
14.THE COMPANY UNDER PROVISIONS OF CHAPTER 1424 OF THE GENERAL LAWS IS REQUIRED TO APPLY FOR AND OBTAIN ALL CONSTRUCTION-RELATED PERMITS THE COMPANY SHALL NOT
BE DEEMED RESPONSIBLE FOR DELAYS IN THE WORK DESCRIBED IN'THIS AGREEMENT CAUSED BY REGULATORY PERMIT GRANTING OR INSPECTIONAL AGENCIES,AUTHORITIES,OR
INDIVIDUALS
IS,THIS AGREEMENT,INCLUDING THE PROVISIONS RELATING TO PRICE AND PAYMENTSCHEDULE'.,CANNOT BE CHANGED OR ALTERED EXCEPT BY A WRITTEN STATEMENT SIGNED RV RUTH THE
COMPANY AND THE CLIENT.
lb.ANY REPRESENTATIONS,STATEMENTS,OR OTHER COMMUNICATION NOT WRITTEN ON THIS AGREEMENT ARE AGREED TO BE IMMATERIAL AND NOT RELIED ON BY EITHER PARTY,AND DO
NOT SURVIVETHE EXECUTION DF THIS AGREEMENT.
17.THIS AGREEMENT CANNOT BE CANCELLED WITHOUT THE MUTUAL WRITTEN CONSENT OF BOTH PARTIES EXCEPT AS OTHERWISE SET FORTH HEREIN.
SE.THIS AGREEMENT,AND ANY WARRANTOR)PROVIDED HEREUNDER SHALE NOTRE ASSIGNED EXCEPT BY ORW!TN THE WRITTEN PERMISSION OF THE COMPANY,
H.IF THE CLIENT FAILS TO PERFORM ITS OBLIGATIONS HEREUNDER OR TERMINATES THIS AGREEMENT WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMPANY,NE CLIENT SHALL BF
LIABLE FOR DAMAGES FOR THE GREATER OFTHE COMPANY'S ARUM DAMAGES OR I5%OF THE AGREEMENT FOR RESTOCKING FEE.
20.ANY CHANGES TO MATERIALS BY THE CLIENT(BRAND.STYLE,COLOR,ETC.]AFTER SAID MATERIAL HAS BEEN DELIVERED OR IS IN ROUTETO THE CLIENT COULD RESULT IN A 5%RESTOCKING
FEE BASED ON THE COST OF SAID MATERIALS.
21.THIS AGREEMENT SHALL BE EFFECTIVE ONLY UPON ITS EXECUTION BY All.PARTIES HERETO,PRIOR TO WHICH TIME IT SHALL BE DEEMED A PROPOSAL.THE COMPANY RESERVE'S THE RIGHT
TOREVOKE THIS PROPOSAL BD DAYS FROM DATE IT iS EXECUTED BY THE COMPANY IF IT IS NUTEARLIER EXECUTED BY THE CUENT AND'THE REQUIRED DOWN PAYMENT RECEIVED PRIOR TO
THE EXPIRATION'S SUCH'#i DAT PERIOD,AFTER S0 DAYS,AND IN THE EVENT COMPANY MfS NOT REVOKE THE PROPOSAL COMPANY RESERVES THE RIGHT TO REVISE ITS PRICE IN
ACCORDANCEWITH ITS COSTS IN EFFECTAT SiCSTIME.
12.IF ANY PROVISION OF THIS AGREEMENT SHOULD BE HELD TO BE INVALID OR UNENFORfABLE THE VALIDITY AND ENFORCEBILRY OF THE REMAINING PROVISIONS OF THIS AGREEMENT
SHALL NOT BE AFFECTED THEREBY.
23 ARBITRATION:IN THE EVEMTHE CLIENT AND COMPANY HAVE A DISPUTE REGARDING ANY OF THE TERMS,CONDITIONS,PROVISIONS OR PERFORMANCE OF THIS AGREEMENT,THE PARTIES
AGREE TO PLACE THE MEMENTO ARBITRATION BEFORE AN INDEPENDENT ARBITRATOR ASSIGNED BY THE AMERICAN ARBITRATION ASSOCIATION TO RESOLVE THEIR DISPUTE.
24.ANY DISCOUNT,PROMOTION,REIMBURSEMENT,OR O11.1ER PROGRAM THAT R PART OF A STATE SPONSERED UTWTY PROGRAM DE.MASS SAVE')155URIECTTO THE AVAIL AVARATENEY Q
QUALIFYING STATE SPONSERED PROGRAM AND WILL BE SUBJECT TO TERMINATION IF THE STATE SPONSEREO UTILITY PROGRAM IS DISCWNDNUED.FURTHERMORE THE'TERMS AND
CONDITIONS OF STATE SPONSERED UTILITY PROGRAMS MAY BE ALTERED OR UPDATED PERIODICALLY WITH OR WITHOUT NOTICE.
15.AMERICAN INSTALLERS.LLC IS NOT AN AGENT OP ANY UTILITY COMPANY OF OTHER VENDOR WORKING BY,THROUGH,OR UNDER THE MASS SAVES ENERGY PROGRAM.
W CLIENT IS REPSONSIBLE FOR THE PAYMENT OF ANY AND ALS FEDERAL STATE,OR LOCAL TARESTHAT ARE APPLICABLE TO THIS AGREEMENT.
The Comnsonwealth of Massachusetts
I. ,.-,_= Department of Industrial Accidents
=t Office of Investigations
!. —7 � 600 Washington Street
d=lily c. Boston,MA 02111
z>a wwn'.ntass,gov/dia
Workers' Compensation Insurance Affidavit Builders/Contractorsfklectricians/Plumbers
Applicant Information Please Print Legihly
Name (BavnessiOrgmtludonnndividuap: American Installations,LLC
Address: 130 College Street„Suite 100
City/Slate/Zip: South Hadley,MA 01075 Phone ii: 413-552-0200
Are you an employer?Cheek the appropriate bun: Type of project(required):
t.riti 1 am a employer with i 31 4. [) I am a general contractor and I
6. ❑ New construction
employees Hull anon part-tine).' have hired the. subcontractors 1
2.IL I am a sole proprietor or partner- listed on the attached sheet, : 7 Remodeling
ship and have no employees These subcontractors have 8. U Demolition
working for me in any capacity. workers' comp. insurance. 9. �...� Building addition
INo workers comp.insurance 5. ❑ We art a corporation and its
required.] officers have exercised their IqJ—� Elec6ical repairs or additions
3.0 I am o homeowner doing all work right of exemption per MGI. ILL j Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no ii
12,1J Roof repairs
insurance restaged.'t employees.[No workers'
comp insurance required.] ( 13.TA OthY Insulation
'Any applicant that cheeksbeal must also ell thearoorwnd theirworkers'a policy lbaon.
'Ilamuwnnrwho
s is this affidavit cid a they aredoing allwork and lave hire ousulb-contcdust submit new
affidavit indicating.
:Gmlmtlzrha check this box must attached on additional sheet rvhnwlu0the name unite sub-contractors aid their workers'comp.Outs ifomalien.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy audit*site
information.
Insurance Company Name: Guard Insurance Companies
Policy ,Policy 0 or Self-ins. lie &((. AMWC731485j�� *' Pao._
pepnatron Daley 09/04/2017 ',AA ^^��
Job Site Address:_..,toe C,'l al fe. P Ciry/State/Zp:_et&ttece ',AA 0tL�te e_„
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of Mit,c, 152 can lead to the imposition of criminal penalties ofa
line up to$1,500.00 audios one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S2:000 a day anaiisi the violator_ Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/de hereby certify nailer the pains and penalties ofperjn y that the information provided above is true and correct.
5i mat:r- e_ r/Ir . i - Date: _._Li3'
1
Phone Pi 413-55 -0200
Y
Official use only. Do not write in this area,to be completed by city or lawn official
City or Town: Permit/License 4
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.Citvfrmvn Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
I Contact Person:
I Phone#:
ACO va CERTIFICATE OF LIABILITY INSURANCE DATE
INWOcu
9/1/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT Linda Manors
Webber & Grinnell lArp11c bx fm. (413)586-0111. 12N, Mtn 5W-6481 _.
8 North Xing Street "MILss:!powers@webberandgrinnell.COM
INSUREMS)AFFORDING COVERAGE NAM It
Northampton MA 01060 INSURER Emplayera Mutual Casualty,
NFSUREn anuRERS$orkahrre Hathaway GIIA1t° l.ne. Co.
Aneriean Installations, LLC INSURER C:
Attn: Wes & Suzanne Couture INSURER 0:
130 College Straetr Suite 100 INSURER E!
South Hadley a1A 01015 mBURERF_
COVERAGES CERTIFICATE NUMBER Laster £%p 9-2017 REVISION NUMBER:
THIS IS TO CERTIFY THAT. THE POLICIES OF INSURANCE LIS!EO BELOW WAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POI..ICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POI'CIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSSRR ,.. ABbL NOW I POLICY Ere POLICY IX _
P I - -
• IMPEDE INSURANCE INBO YAM PODGY NUMBER I IMMOWYTY)I IMMmorroYI I LIMITS
COMMERCIALGENERAL LIAWLT" 1 - EACH OCCURRENCE 5 1,000,000
A I'' 1 X j CLAIMS-MADE/ONBNADE OCCUR PR G 0 Fg4nOMnce) •5 500,000
`X Lasuor Liability 503535211 19/4/2016 9/4/2017 MED Exp y ww(Wwn) I$ 10,000
PERSONALS ADVINJURY $ 1,000,000
GEN-1 AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3.000,000
X_Wt;CY_PEQ LO
_ C f PRODUCTS.COMCXWAGG S 2,$00,000
S
OMdenS
AUTRRI E LINEALLY IICOMS�INFo SINGLE LIMIT F 1,000,000
A --'ANY AUTOBO0 (Pieper-son) S
ALL OWNEDK SCHEDULED 5£3535217 9/4/2016 9/4/2017 1 BODILY INJURY(Pet a.aee,1
AUTOX HIRED<LTOE X NON-OVMEO :..A EKY DAMAGE S
AUTOS .4 ?L S.
PIP-Basic :E 8,000
X UMBRELLA LIAR .1---IS
OCCUR EACH OCCURRENCE S 1,000,000
A EXCESS SIAe ICLAWS-MADE: 1 AGGREGATE IS 1 000,000
0E0 11 X RETENTION 10,000 1 543533217 9/4/201.6 9/4/2017 IS
woRNEEgCOMPENSA11411 : % PERRE .ETH
ANO PRDPRYERSIDLOR AIDLM Y f N`
ANY MEMER EXCLUDED'
Et EACHACCIDENT S 500,000
B mandatory innNER E%CW DFD? iNlr`I ORMC609917 9/4/2016 9/4/2017
IIt es.SeC RN) E DISEASE LEMPLOVEE5 $00,000
s E'er
DESCRIPTION OF OPERATIONS below E L DISEASE—POLICY LIMIT I$ 500 000
A Covmmrc,al Property 5w3535211 9/4/2016 19/4/2011 uemehem SL 000 $20,000
i ,um2Les:coo $40,000
DESCRIPTION 0P OPE511ON5 rLOCAT W S f VEHICLES IACORD 101,Additional Remits SAIRd IC.may be auchs N more spate M method)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
MEMORIZED REPRESENTAuVE j
i )i:e'✓ir. Joyce/LNP "" 4—_. _
EO 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered(narks of ACORD
1N3025 I?n,LPL
IFMassachusetts -Department of Public Safety Unrestricted-Buildings of any use group which
Board of Building Regulations and Standards contain less than 35,000 cubic feet(991m)of
Cons:ruUi n Supers co =OM enclosed space.
License: fS-106178
Tl
WESLEY COUTO*IE - v4'4. -
166 NORTH MArot
South Badley IRA;01 /J
V Failure to possess a current edition of the Massachusetts
r Expiration State Building Code is cause for revocation of this license.
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Commissioner 09/29/2017 far OPS liceamgmformationnsit www.Mass.Gov/OP5
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192PQ .P.C7i> G 0./ i i (y
Office of Consumer Affairs and Busi ss Reg'.-lation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 175982
Type: LLC
Expiration: 627/2017 Tr# 265208
AMERICAN INSTALLATIONS, LLC
WESLEY COUTURE
130 COLLEGE STREET SUITE 100 -
SOUTH HADLEY, MA 01075
Update Address and return card.Mark reason for change.
scar a 20M 05/11 - Address n Renewal E Employment Q Lost Card
rrl4e Vcimmowemild
Office fConsumer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
e9istrauon: 175962 Type: Office of Consumer Affairs and Business Regulation
Expiration: 6/27/2017, LLC 10 Park Plaza Suite 5170
Boston,MA 02116
AMERICAN INSTALLATIONS,LLC
WESLEY COUTURE �j� ,/
130 COLLEGE STREET SUITE 100 //^/(,/
SOUTH HADLEY,MA 01075 Undersecretary N alid without signature